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Examination

History

The patient is a 50-year-old, married, Caucasian, English-speaking man.

History of Present Illness:

The patient slipped and fell backward while walking his dog outside the home. He did not lose consciousness, but was immediately unable to move his arms or legs and experienced altered sensation below the neck. Magnetic resonance imaging (MRI) revealed a spinal cord contusion, cord stenosis, and cord compression between C2 and C4. He underwent spinal fusion of C2-C4 with posterior cervical laminectomy and lateral plating.

Admitting Diagnosis:

The admitting diagnosis was C4 spinal cord injury (SCI). Based on the American Spinal Injury Association Impairment Scale (AIS), the lesion was designated as a Category C: Incomplete. Sensory and motor function is preserved below the neurological level and includes the sacral segments S4-S5. The patient was admitted wearing a cervical orthosis (Fig. CS14.1).

Medical History:

Hypertension and hyperlipidemia (no medications prior to admission)

Surgical History:

None prior to admission

Social History:

The patient enjoys his work, family, grandchildren, and attending college athletic events. He works at a nuclear power plant full time as the director of maintenance.

Living Environment:

He lives in a ranch-style home with one step to enter with a tub/shower combination in the bathroom.

Prior Level of Function:

He was fully independent prior to the accident and stayed active by walking his dog daily.